Anesthesia Considerations for Patients with Schizophrenia
According to the Diagnostic and Statistical Manual of Disease (DSM) (version V), schizophrenia-associated psychotic disorders are characterized by disturbances in emotional, behavioral and cognitive arenas, impeding on nearly every aspect of life functioning in the form of thought disorders, delusions, and hallucinations (1). To date, this devastating psychiatric disease represents the most common psychotic disorder, currently affecting approximately 20% of all people treated for mental illness (2). Since the early 1900s, schizophrenia and psychotic disorders have been recognized as posing a challenge to safe and efficient anesthesia management (3). However, given the rise of schizophrenia-associated psychosis, as well as the number of both emergency and elective surgeries, a careful consideration of increasingly specific and empirically-driven protocols and best practices is warranted (4).
In light of this, schizophrenia primarily incurs 1) difficulties with patient communication, 2) pharmacological challenges linked to interactions between antipsychotic and anesthetic drugs, and 3) difficulties associated with the presence of concomitant schizophrenia-associated pathologies, including disturbances in the endocrine, immune, and cardiovascular systems (2).
Pre-operatively, acquiring consent to undergo anesthesia requires that a person is able to understand the information presented, retain this information, use it to make an informed decision, and communicate their decision (5). Although mental illness may impair one’s ability to carry out an informed decision regarding treatment, this should not initially be assumed to be the case. In cases in which patient incapacity is irreversible, however, and there is no Advanced Decision or Lasting Power of Attorney (LPA) or country-specific judicial equivalent, it is the anesthesia provider’s responsibility to treat the patient in their best interests.
Furthermore, both pre- and postoperatively, patients with schizophrenia are difficult to communicate with as they may be uncooperative or aggressive (1). This said, a recent report of 5 patients with schizophrenia receiving anesthesia highlighted the importance of a team that treats patients in a humane and a detail-oriented manner. Cooperation with the psychiatrist in charge and a good management system in the inpatient department, including careful and frequent patient observation, should ensure smooth anesthesia management of schizophrenic patients (6).
Beyond patient communication skills, knowledge of the pharmacological profile, side-effects, and drug interactions is of critical importance to the administration of anesthesia. Indeed, psychoactive drugs frequently administered include antidepressants, mood stabilizers, antipsychotics, and anxiolytics – all of which have precise guidelines with regard to the administration of anesthesia which should be thoroughly researched and abided by (7). For example, patients’ selective serotonin reuptake inhibitors and tricyclic antidepressants should be continued throughout the operative period. Careful consideration is also required for patients on monoamine oxidase-A inhibitors (MAOIs), in whom pethidine and indirectly acting sympathomimetics are strictly contraindicated. Finally, a recent case report illustrated neuroleptic malignant syndrome as an uncommon yet life-threatening condition resulting from antipsychotic agents which must always be kept in mind when administering anesthesia to patients with schizophrenia (1). As such, careful consideration of a number of alternative anesthetics, informed by the psychotropic medication and any specific anesthetic/adjuvant drug interactions, is a cornerstone to ensuring good patient outcomes (4).
Furthermore, when patients are on psychotropic medications, regional anesthesia is a safer alternative than general anesthesia. The advantages of regional over general anesthesia primarily include a decreased incidence of postoperative nausea and vomiting, avoidance of airway instrumentation, early mobility, and a decreased postoperative intensity of care. Further benefits include increased alertness, decreased recovery time, minimum postoperative delirium and confusion, and the prevention of any interactions of antipsychotic medications with general anesthesia drugs (8). Since these patients have severe anxiety and may not cooperate during the preparation of regional and nerve blocks, the main obstacle to administering regional anesthesia in these patients remains the difficulty of communicating the merits of regional anesthesia.
While these considerations lay the foundation for the efficient anesthetic care of patients with schizophrenia, a number of challenges linked to their unique physiologies remain. Perioperatively, as a result of an impaired response to stress, physiological complications include arrhythmias, hypotension, prolonged narcosis or coma, hyperpyrexia, postoperative ileus, and postoperative confusion (9). Furthermore, chronic schizophrenic patients lack pain sensitivity, experience pituitary-adrenal and autonomic nerve dysfunction and disordered immune systems, and suffer from water intoxication – all of which can interfere with and compromise postoperative outcomes. Including for these reasons, patients with schizophrenia receiving chronic antipsychotic therapy remain plagued by an increased mortality rate in the postoperative period (10). Therefore, it is important for anesthesiologists to consider these unique physiological dispositions and cater anesthetic care accordingly.
Patients with schizophrenia are challenging to anesthesia providers due to the inherent behavioral characteristics of their illness on top of the physiological side-effects of psychotropic medications. Managing these patients warrants the acquisition of specialized clinical skills and comprehensive knowledge of the pathophysiological and pharmacological aspects of their medications and physiologies in order to most effectively tailor anesthetic care.
References
- Constance LSL, Lansing MG, Khor FK, Muniandy RK. Schizophrenia and anaesthesia. BMJ Case Rep. 2017;2017. doi:10.1136/bcr-2017-221659
2. Kudoh A. Perioperative Management for Chronic Schizophrenic Patients. Anesth Analg. 2005 Dec;101(6):1867–72.
3. Doyle JB. POST-ANAESTHETIC AND POST-OPERATIVE PSYCHOSIS.
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6. ISHIKAWA M, KAMEKURA N, FUJISAWA T, KITAGAWA E, FUKUSHIMA K, FUKUDA H. A Clinical Study on General Anesthetic Management of Schizophrenic Patients. J Japanese Stomatol Soc. 1997 Jan 10;46(1):9–13.
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9. Kudoh A, Kimura F, Murakawa T, Ishihara H, Matsuki A. Perioperative management of patients on long-term administration of psychotropic drugs. Japanese J Anesthesiol. 1993.
10. Matsuki A, Oyama T, Izai S, Zsigmond EK. Excessive mortality in schizophrenic patients on chronic phenothiazines treatment. Agressologie. 1972.